Bernd A. Leidel

Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins

INTRODUCTION Current European Resuscitation Council (ERC) guidelines recommend intraosseous (IO) vascular access, if intravenous (IV) access is not readily available. Because central venous catheterisation (CVC) is an established alternative for in-hospital resuscitation, we compared IO access versus landmark-based CVC in adults with difficult peripheral veins. METHODS In this prospective observational study we investigated success rates on first attempt and procedure times of IO access versus central venous catheterisation (CVC) in adults (≥ 18 years of age) with inaccessible peripheral veins under trauma or medical resuscitation in a level I trauma centre emergency department. RESULTS Forty consecutive adults under resuscitation were analysed, each receiving IO access and CVC simultaneously. Success rates on first attempt were significantly higher for IO cannulation than CVC (85% versus 60%, p=0.024) and procedure times were significantly lower for IO access compared to CVC (2.0 versus 8.0 min, p<0.001). As for complications, failure of IO access was observed in 6 patients, while 2 or more attempts of CVC were necessary in 16 patients. No other relevant complications like infection, bleeding or pneumothorax were observed. CONCLUSIONS IO vascular access is a reliable bridging method to gain vascular access for in-hospital adult patients under resuscitation with difficult peripheral veins. Moreover, IO access is more efficacious with a higher success rate on first attempt and a lower procedure time compared to landmark-based CVC.

Consistency of Long-Term Outcome of Acute Rockwood Grade III Acromioclavicular Joint Separations After K-Wire Transfixation

BACKGROUND Surgical approach to acute Rockwood grade III acromioclavicular (AC) joint injuries demands satisfying and reliable treatment results of shoulder function in the long term. This study investigates the operative outcome of acute grade III AC joint separations after temporary K-wire transfixation of the AC joint over the years. We hypothesize, that the well-established temporary articular transfixation of acute Rockwood grade III AC joint dislocations with K-wires provides good and consistent functional outcome at long term. METHODS Seventy patients who underwent temporary articular transfixation of the AC joint followed by a standardized rehabilitation program and early physiotherapeutic exercising were divided into three follow-up cohorts. The treatment results were investigated 1 to 2 years (short-term, group A, n = 18), 3 to 5 years (mid-term, group B, n = 33), and 6 to 10 years (long-term, group C, n = 19) after surgical procedure. The outcome was measured using a standardized functional patient questionnaire including Constant score, ASES rating scale, SPADI, and XSMFA-D score. The results given in average and mean +/- SD were compared between the three cohorts by calculating the Kruskal-Wallis one way analysis for variance on ranks. RESULTS Average patient age at time of surgical therapy was 37 (+/-11) years without significant difference between the three cohorts. Independent of follow-up period all patients demonstrated good functional treatment results in the long run expressed by an over all Constant score of 88 (+/-10) points, ASES rating scale of 29 (+/-3) points, SPADI of 3 (+/-9) points, XSMFA-D function score of 13 (+/-2) points, and XSMFA-D impairment score of 4 (+/-1) points, respectively. The comparison of the three follow-up groups proved no significant differences in outcome over a maximum follow-up period of up to 10 years. However, the longer the follow-up period, the tendency of the promising treatment outcome becomes more stable. CONCLUSIONS Temporary K-wires fixation of acute Rockwood grade III AC joint separations enable good long-term results in shoulder function. The achieved functional outcome parameters reveal a high consistency in the long run over the years.

Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: A prospective, randomized study

INTRODUCTION Current guidelines recommend intraosseous (IO) vascular access in adults if peripheral venous access is unavailable. Most available data derive from children, animal models, cadaver studies or the prehospital setting. Therefore we compared two different IO access devices in adults under resuscitation in the hospital setting. PATIENTS AND METHODS This prospective, randomized clinical study compared two different IO access devices in adults (>/=18 years of age) under trauma or medical resuscitation admitted to our emergency department with impossible peripheral venous access. Each adult was randomized to either spring-loaded BIG Bone Injection Gun or battery-powered EZ-IO. Outcome measures included success rates on first attempt, procedure times and complications. RESULTS Forty consecutive adults under resuscitation were enrolled. Twenty patients received the BIG, another twenty patients the EZ-IO. Over all success rate on first attempt was 85% and mean procedure time 2.0min+/-0.9. Comparing the two devices, success rate on first attempt was 80% for the BIG versus 90% for the EZ-IO and mean procedure time was 2.2min+/-1.0 for the BIG versus 1.8min+/-0.9 for the EZ-IO. The differences between both IO devices were not statistically significant. No other relevant complications like infection, extravasation or bleeding were observed. CONCLUSIONS IO vascular access was a reliable and safe method to gain rapid vascular access for in-hospital adult emergency patients under resuscitation. Further studies are necessary regarding comparative effectiveness of different IO devices.

Computed tomography during cardiopulmonary resuscitation using automated chest compression devices--an initial study.

The purpose of the study was to evaluate both CT image quality in a phantom study and feasibility in an initial case series using automated chest compression (A-CC) devices for cardiopulmonary resuscitation (CPR). Multidetector CT (MDCT) of a chest/heart phantom (Thorax-CCI, QRM, Germany) was performed with identical protocols of the phantom alone (S), the phantom together with two different A-CC devices (A: AutoPulse, Zoll, Germany; L: LUCAS, Jolife, Sweden), and the phantom with a LUCAS baseplate, but without the compression unit (L-bp). Nine radiologists evaluated image noise quantitatively (n = 244 regions, Student’s t-test) and also rated image quality subjectively (1–excellent to 6–inadequate, Mann-Whitney U-test). Additionally, three patients during prolonged CPR underwent CT with A-CC devices. Mean image noise of S was increased by 1.21 using L-bp, by 3.62 using A, and by 5.94 using L (p < 0.01 each). Image quality was identical using S and L-bp (1.64 each), slightly worse with A (1.83), and significantly worse with L (2.97, p < 0.001). In all patient cases the main lesions were identified, which led to clinical key decisions. Image quality was excellent with L-bp and good with A. Under CPR conditions initial cases indicate that MDCT diagnostics supports either focused treatment or the decision to terminate efforts.

Outcome analysis following removal of locking plate fixation of the proximal humerus

BackgroundConcerning surgical management experience with locking plates for proximal humeral fractures has been described with promising results. Though, distinct hardware related complaints after fracture union are reported. Information concerning the outcome after removal of hardware from the proximal humerus is lacking and most studies on hardware removal are focused on the lower extremity. Therefore the aim of this study was to analyze the functional short-term outcome following removal of locking plate fixation of the proximal humerus.MethodsPatients undergoing removal of a locking plate of the proximal humerus were prospectively followed. Patients were subdivided into the following groups: Group HI: symptoms of hardware related subacromial impingement, Group RD: persisting rotation deficit, Group RQ: patients with request for a hardware removal. The clinical (Constant-Murley score) and radiologic (AP and axial view) follow-up took place three and six months after the operation. To evaluate subjective results, the Medical Outcomes Study Short Form-36 (SF-36), was completed.Results59 patients were included. The mean length of time with the hardware in place was 15.2 ± 3.81 months. The mean of the adjusted overall Constant score before hardware removal was 66.2 ± 25.2% and increased significantly to 73.1 ± 22.5% after 3 months; and to 84.3 ± 20.6% after 6 months (p < 0.001). The mean of preoperative pain on the VAS-scale before hardware removal was 5.2 ± 2.9, after 6 months pain in all groups decreased significantly (p < 0.001). The SF-36 physical component score revealed a significant overall improvement in both genders (p < 0.001) at six months.ConclusionA significant improvement of clinical outcome following removal was found. However, a general recommendation for hardware removal is not justified, as the risk of an anew surgical and anesthetic procedure with all possible complications has to be carefully taken into account. However, for patients with distinct symptoms it might be justified.

Analysis of N-terminal pro-B-type natriuretic peptide and cardiac index in multiple injured patients: a prospective cohort study

IntroductionIncreased serum B-type natriuretic peptide (BNP) has been identified for diagnosis and prognosis of impaired cardiac function in patients suffering from congestive heart failure, ischemic heart disease, and sepsis. However, the prognostic value of BNP in multiple injured patients developing multiple organ dysfunction syndrome (MODS) remains undetermined. Therefore, the aims of this study were to assess N-terminal pro-BNP (NT-proBNP) in multiple injured patients and to correlate the results with invasively assessed cardiac output and clinical signs of MODS.MethodsTwenty-six multiple injured patients presenting a New Injury Severity Score of greater than 16 points were included. The MODS score was calculated on admission as well as 24, 48, and 72 hours after injury. Patients were subdivided into groups: group A showed minor signs of organ dysfunction (MODS score less than or equal to 4 points) and group B suffered from major organ dysfunction (MODS score of greater than 4 points). Venous blood (5 mL) was collected after admission and 6, 12, 24, 48, and 72 hours after injury. NT-proBNP was determined using the Elecsys proBNP® assay. The hemodynamic monitoring of cardiac index (CI) was performed using transpulmonary thermodilution.ResultsSerum NT-proBNP levels were elevated in all 26 patients. At admission, the serum NT-proBNP values were 116 ± 21 pg/mL in group A versus 209 ± 93 pg/mL in group B. NT-proBNP was significantly lower at all subsequent time points in group A in comparison with group B (P < 0.001). In contrast, the CI in group A was significantly higher than in group B at all time points (P < 0.001). Concerning MODS score and CI at 24, 48, and 72 hours after injury, an inverse correlation was found (r = -0.664, P < 0.001). Furthermore, a correlation was found comparing MODS score and serum NT-proBNP levels (r = 0.75, P < 0.0001).ConclusionsSerum NT-proBNP levels significantly correlate with clinical signs of MODS 24 hours after multiple injury. Furthermore, a distinct correlation of serum NT-proBNP and decreased CI was found. The data of this pilot study may indicate a potential value of NT-proBNP in the diagnosis of post-traumatic cardiac impairment. However, further studies are needed to elucidate this issue.

Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study

Background: Acute aortic syndromes (AASs) are rare and severe cardiovascular emergencies with unspecific symptoms. For AASs, both misdiagnosis and overtesting are key concerns, and standardized diagnostic strategies may help physicians to balance these risks. D-dimer (DD) is highly sensitive for AAS but is inadequate as a stand-alone test. Integration of pretest probability assessment with DD testing is feasible, but the safety and efficiency of such a diagnostic strategy are currently unknown. Methods: In a multicenter prospective observational study involving 6 hospitals in 4 countries from 2014 to 2016, consecutive outpatients were eligible if they had ≥1 of the following: chest/abdominal/back pain, syncope, perfusion deficit, and if AAS was in the differential diagnosis. The tool for pretest probability assessment was the aortic dissection detection risk score (ADD-RS, 0–3) per current guidelines. DD was considered negative (DD−) if <500 ng/mL. Final case adjudication was based on conclusive diagnostic imaging, autopsy, surgery, or 14-day follow-up. Outcomes were the failure rate and efficiency of a diagnostic strategy for ruling out AAS in patients with ADD-RS=0/DD− or ADD-RS ⩽1/DD−. Results: A total of 1850 patients were analyzed. Of these, 438 patients (24%) had ADD-RS=0, 1071 patients (58%) had ADD-RS=1, and 341 patients (18%) had ADD-RS >1. Two hundred forty-one patients (13%) had AAS: 125 had type A aortic dissection, 53 had type B aortic dissection, 35 had intramural aortic hematoma, 18 had aortic rupture, and 10 had penetrating aortic ulcer. A positive DD test result had an overall sensitivity of 96.7% (95% confidence interval [CI], 93.6–98.6) and a specificity of 64% (95% CI, 61.6–66.4) for the diagnosis of AAS; 8 patients with AAS had DD−. In 294 patients with ADD-RS=0/DD−, 1 case of AAS was observed. This yielded a failure rate of 0.3% (95% CI, 0.1–1.9) and an efficiency of 15.9% (95% CI, 14.3–17.6) for the ADD-RS=0/DD− strategy. In 924 patients with ADD-RS ⩽1/DD−, 3 cases of AAS were observed. This yielded a failure rate of 0.3% (95% CI, 0.1–1) and an efficiency of 49.9% (95% CI, 47.7–52.2) for the ADD-RS ⩽1/DD− strategy. Conclusions: Integration of ADD-RS (either ADD-RS=0 or ADD-RS ⩽1) with DD may be considered to standardize diagnostic rule out of AAS. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02086136.

Intraossäre Fehlpunktion@@@Failure of intraosseous vascular access: Notwendigkeit adäquater Schulung für den erfolgreichen Einsatz intraossärer Infusionen beim Erwachsenen@@@The need for appropriate training for successful application of intraosseous infusion in adults

ZusammenfassungDie Anlage eines periphervenösen Zugangs kann insbesondere in Notfallsituationen erschwert oder gar unmöglich sein. Intraossäre (IO-) Punktionskanülen erlauben auch unter widrigen Bedingungen einen vaskulären Zugang, da die reichlichen intramedullären Gefäße nicht kollabieren und somit applizierte Medikamente und Infusionen rasch in den zentralen Kreislauf transportieren. In den aktuellen umfassenden Empfehlungen des European Resuscitation Council (ERC) wird daher mittlerweile der IO-Zugang als sekundärer Zugang auch beim Erwachsenen favorisiert, falls primär die rasche periphere Venenpunktion unmöglich ist.Voraussetzung für die erfolgreiche Anwendung eines IO-Zugangs ist die entsprechende Einweisung mit Schulung und Training in das Produkt. Die fehlende oder unzureichende Einweisung kann zu Komplikationen führen. Im vorliegenden Fall berichten wir über die fehlerhafte Anlage eines IO-Zugangs bei einem Schwerstverletzten im Rahmen der Schockraumversorgung. Aufgrund inkorrekter Lagerung des Verletzten und falscher Handhabung der IO-Punktionskanüle kam es dabei zu deren Fehlplatzierung. Die Gabe von Medikamenten oder Infusionen war damit über diesen Zugang nicht möglich.AbstractIn cases of emergency it can sometimes be difficult or even impossible to achieve peripheral venous access. However, intraosseous (IO) devices enable vascular access even under adverse conditions due to the abundant, non-collapsible intramedullary vessels which are able to rapidly transport drugs and infusions to the central circulation. Therefore, the current European Resuscitation Council (ERC) guidelines favour IO access even in adults if rapid peripheral venous catheterization is not possible.Appropriate training in homologous IO devices is imperative for successfully achieving vascular access. Lacking or insufficient training may lead to complications. The present article describes a case of incorrect IO device application on a severely injured patient in the resuscitation room. Flawed patient positioning and incorrect handling of the IO device led to displacement of the device. Therefore, the intraosseous administration of drugs or infusions was not possible.

Serum GFAP and UCH-L1 for prediction of absence of intracranial injuries on head CT (ALERT-TBI): a multicentre observational study

BACKGROUND More than 50 million people worldwide sustain a traumatic brain injury (TBI) annually. Detection of intracranial injuries relies on head CT, which is overused and resource intensive. Blood-based brain biomarkers hold the potential to predict absence of intracranial injury and thus reduce unnecessary head CT scanning. We sought to validate a test combining ubiquitin C-terminal hydrolase-L1 (UCH-L1) and glial fibrillary acidic protein (GFAP), at predetermined cutoff values, to predict traumatic intracranial injuries on head CT scan acutely after TBI. METHODS This prospective, multicentre observational trial included adults (≥18 years) presenting to participating emergency departments with suspected, non-penetrating TBI and a Glasgow Coma Scale score of 9-15. Patients were eligible if they had undergone head CT as part of standard emergency care and blood collection within 12 h of injury. UCH-L1 and GFAP were measured in serum and analysed using prespecified cutoff values of 327 pg/mL and 22 pg/mL, respectively. UCH-L1 and GFAP assay results were combined into a single test result that was compared with head CT results. The primary study outcomes were the sensitivity and the negative predictive value (NPV) of the test result for the detection of traumatic intracranial injury on head CT. FINDINGS Between Dec 6, 2012, and March 20, 2014, 1977 patients were recruited, of whom 1959 had analysable data. 125 (6%) patients had CT-detected intracranial injuries and eight (<1%) had neurosurgically manageable injuries. 1288 (66%) patients had a positive UCH-L1 and GFAP test result and 671 (34%) had a negative test result. For detection of intracranial injury, the test had a sensitivity of 0·976 (95% CI 0·931-0·995) and an NPV of 0·996 (0·987-0·999). In three (<1%) of 1959 patients, the CT scan was positive when the test was negative. INTERPRETATION These results show the high sensitivity and NPV of the UCH-L1 and GFAP test. This supports its potential clinical role for ruling out the need for a CT scan among patients with TBI presenting at emergency departments in whom a head CT is felt to be clinically indicated. Future studies to determine the value added by this biomarker test to head CT clinical decision rules could be warranted. FUNDING Banyan Biomarkers and US Army Medical Research and Materiel Command.

[Mild head injury in children and adults: Diagnostic challenges in the emergency department].

Mild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.ZusammenfassungDas leichte Schädel-Hirn-Trauma (SHT) ist eines der häufigsten Verletzungsbilder in Notfallaufnahmen und birgt besondere Herausforderungen. Einerseits sind relevante Verletzungsfolgen selten, andererseits gibt es Fälle, bei denen verzögert oder gar nicht erkannte Verletzungen fatale Konsequenzen nach sich ziehen. Das initial meist unauffällige klinische Erscheinungsbild korreliert häufig nicht mit dem Verletzungsausmaß. Säuglinge und kleine Kinder sind aufgrund ihrer noch fehlenden oder erst beginnenden kognitiven und sprachlichen Entwicklung oftmals schwierig einzuschätzen, besonders für im Umgang mit dieser Altersgruppe nichterfahrene Untersucher. Etablierte Checklisten für klinische Risikofaktoren einer intrakraniellen Verletzung bei Kindern und Erwachsenen ermöglichen allerdings die differenzierte und rationale Indikationsstellung zur Computertomographie des Schädels. Relevante Verletzungsfolgen können so sicher erkannt und zugleich eine unnötige Strahlenbelastung vermieden werden.AbstractMild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.